Reducing Readmission Case StoriesDiscussion of SuccessesUniversity of California, San FranciscoMaureen Carroll RN, CHFNTransitional Care ManagerHeart Failure Program Coordinator

UnityPoint Cedar Rapids Iowa Peg Bradke RN, MA

Vice President, Post Acute Care

UnityPoint Health St. Luke’s

University of California, San Francisco

Mission: The reason that we exist is Caring, Healing, Teaching, and Discovery

Top 10 Hospitals (US World and News past 13 yrs)

722 licensed beds; 28,000 admissions,

New UCSF Mission Bay Hospitals

– Benioff Children’s Hospital

– Betty Irene Moore Woman’s Hospital

– Bakar Cancer Hospital

– Ron Conway Family Gateway Medical Building

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The Cross Continuum Team

Multidisciplinary cross continuum team – it takes a village;

Family caregivers, nurses, physicians, senior leadership, case managers, social workers, dieticians, pharmacists, nurse practitioners, home care team, palliative care, Care Support team, chaplains, managers, community partners, SNF liaisons, outpatient clinic liaisons, community clinics liaisons, and more

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The Cross Continuum Team

Excellence in Transitions of Care – ETOC

Workgroups – Hospital wide readmission projects

Data review and management

Highlights on progress on projects/programs

Inpatient and outpatient programs

Senior leadership participation

Office of Population Health

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Cross Continuum Teams

UCSF Care Support

UCSF Bridges

UCSF Housecalls

UCSF Center for

Geriatrics Care

UCSF-Hastings

Medical Legal

Partnership for

Seniors

St. Luke’s Hospital - UnityPoint Health

System

Private hospital – Cedar Rapids, Iowa

Affiliate in the UnityPoint Health System

Licensed for 500 Beds with more than 17,000 admissions

Truven Top 100 Hospital – 5 years; Heart Hospital - 3 years

Iowa Recognition for Performance Excellence Gold Award - 2010

Joint Commission Disease-Specific Recertifications in Stroke (2006-14), Heart Failure (2008-14), Total Joint (2008-14) and Palliative Care (2010-14).

Society of Chest Pain Center – Chest Pain Certification (2010, 2013)

Magnet Re-designation – 2014

Mayo Clinic Care Network – 2014

CCT – Transition to Home

Our mission: “To give the healthcare we’d like our loved ones to receive”

Meets monthly

Reviews readmissions for each month related to core diagnosis to assess causes and opportunities for improvement

Reviews process and outcome measures

Continually testing and improving, aggregating the experiences of patients, families and caregivers

Each site/level of care reports on testing occurring in their area

Transition to Home Team Members

Inpatient Nursing Units

– Manager

– Care Managers

Palliative Care

Home Care

Respiratory Care

Emergency Dept.

Case Management

CardioPulm. Rehab.

Pharmacy

Nurse Practitioners

UnityPoint Clinics Reps

Critical Access Hospital

Community SNF’s

Hospitalist Rounding Nurses

Outpatient Social Services

Inpatient Social Services

Performance Improvement

Several Subgroups Report into the

Larger Transition to Home Team

Data Management

Patient Education Processes

Home Care

SNF/Nursing Facilities Work Processes

Physician Clinic Processes

Case Management/Social Work/Care Coordination

Several members of the Transition to Home team are members of the hospital ACO and Population Health Management work. Information is bidirectional between these teams.

Program Overview

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Overview of the Process

Standardized evidence-based care through order sets.

Patient Education/Teaching:

– Utilizing Universal Health Literacy Concepts

– Enhanced teaching materials

– Teach back

Utilization of whiteboard to individualize patient’s plan of care and communicate to team.

Bedside Report

Transition to Home Huddles

Continuum of Care (Cont’d)

Touch points post discharge:Home Care - care coordination visit 24 to 48 hours post discharge on high-risk patientsPhysician Clinic follow-up appointment made prior to discharge for 3-7 days afterWork closely with PCP offices on Transitional Code (TCM) and Patient Centered Medical Home Standardized tool for transfer of information to nursing facilities for next level of care.Telehealth monitor available through Home CareEmergency Department Consistent Care Program Advanced Medical Team Outpatient Social WorkerPalliative Care Program

The Foundation

Monthly Heart Failure Grant Meetings with Multidisciplinary Team

Comprehensive Patient Education

Care coordination

Implemented IHI Evidence Based Interventions

Development of Data Collection System

Patient Advisory Group, Heart Healthy classes on unit

Palliative Care Collaboration

Staff trained on Teach Back & HF Education

Patient stories shared to drive change

Focus on Continuum of Care - Communication and Collaboration

Patient Interventions

Patient Identification- Daily Chart Reviews

Extensive Patient and Family education

Referrals: Inpatient and Outpatient

Follow-up Appointments– Within 7 days for primary HF, COPD, PNA,AMI

– Heart Failure Clinic NPs visits for high risk patients

– Outpatient programs for high risk patients

Follow-up calls – Increased with automation to 5/month

Medication Reconciliation- Pharmacist consult

Discharge Summaries- within 48 hours

Hand off Communication to Outpatient providers

Care at Home Programs – High Risk patients

Outpatient Focus

Collaboration with Outpatient Providers

– Skilled Nursing Facilities, Home Care Agencies, Primary Care Physicians, and Cardiologists

“Virtual Team” Email to connect providers (in/outpatient)

Geriatric Transitions, Consultation, and Comprehensive Care (GeriTraCCC) started UC–Care Support at Home

MD House Calls for High Risk HF Patients (Aug 2010)

Advanced Heart Failure Clinic; High Risk pts- NP follow up

In-services for staff, home care, skilled nursing staff

Hospital wide projects to standardize and improve discharge process and readmission projects

Assessment

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UCSF MDR Improvements

Quieter space

New team monthly- welcome and orientation

Clear expectations for all members

Readmission discussions

What can we do differently?

Address level of support needed

Risk discussed

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Readmission Interviews

Gain perspective of patient and family caregivers

Reach out to inpatient and outpatient providers

Notification of # of admissions in past year, 30 and 90 day readmits, and possible factors

Low health literacy

Lack of support

Medication challenges

Transportation challenges

Assessments: Cognitive, depression, functional, motivation

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The Patient Story …

to share and learn from

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Enhanced Assessment

During Admission Assessment, the patient and family are asked, “Who would you like to have present when we provide your discharge information?”

Medication reconciliation: Dedicated Admission Center RN’s complete home medication list and prepare an appropriate list for physician to address.

Readmission Interviews

Whiteboard

Multidisplinary Rounds

Bedside shift report

– To involve patient and family caregivers as partners in care

Daily discharge huddles

– Identification of patient/family needs/concerns

– Daily goals are reviewed

– Available support for patient: need for Palliative Care Referral

– Educational needs

– Identification of home care needs/other levels of care

– Nurse sensitive indicators: fall risk, skin issues

Patient Education/Teach Back

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Enhanced Teaching and Learning

Same materials are used across the continuum: in the hospital, with home care, long-term care settings and the clinics.

Short, succinct patient/family education packet

Teach Back questions part of packet

Patient teaching flowsheets “close the loop” to help staff nurses address Teach Back and assure the documentation and use of Teach back.

Example: MI 2nd page with TB questions

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Example from EPIC

Patient Teaching Flowsheet

Teach Back Utilized with Discharge

Instructions

Can you show me on these instructions:

– How you find your doctors’ office appointment?

– What other tests you have scheduled and when?

Is there anything on these instructions that could be difficult for you to do?

Have we missed anything?

Who will you call if you have questions?

Discharge SmartPhrase

Patient Education

Teach Back Technique- WORKS

Health Literacy principles

Multiple languages- use of interpreters

Input from patients and family caregivers

Same materials and technique across the Continuum of Care

Educate patient regarding diagnosis, self –care management, and importance of follow up

Lesson Learned: Listen before we teach. Ask open-ended questions

Goal for Patient: Take action when you notice a change in your health

Real-Time Handover

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Real-Time Handover Communications

“Warm Hand-overs” to Skilled Nursing Facilities, Home care agencies, outpatient clinics, and providers

Email-notifications to inpatient team, case manager, consultants, HF clinic, home care RNs, SNF and PCP on admission

Creates a “Virtual Care Team”

Time consuming but valuable

Unites the entire team working on transition of care

Importance of Home Care referrals

– Medication reconciliation

– Focus on self management skills

Email to Team on Admission:Dear Medical Team,We wanted to let you know that we are following Mr. XXXXXXXXXXX in the Heart Failure / Transitional Care Program . We are very familiar with this high risk patient from previous admissions (5th in past 4 months). We have provided education, initiated palliative care consults, and coordinated services in the past . We would like to provide as much support as possible for the patient and family.

Recommendations:1.Bridges Program- MD home visits 2.UC RN home care 3.Pharmacist consult for discharge medications4.Follow up appointment within 7 days5.Goals of care discussion/Palliative care consult

The goal of this program is to provide our Medicare patients and families with as much information and support as possible to enable them to safely manage their care during this vulnerable post hospitalization period, and to prevent avoidable 30 day readmissions. We will be following patients with primary heart failure, COPD, PNA, and AMI. We will be sharing information through tracking of the readmissions to identify trends and to learn from. The focus of the program is as follows;

In-house consults when indicated – dietary, pharmacist, palliative careGoals of care conversations initiated ( by the team or PCS) for all patients admitted 3 times within a yearRN/PT home care visits whenever deemed appropriateFollow up appointments scheduled within 7 days for primary heart failure patients and 14 days for all others at time of dischargeFollow up calls through the UCSF discharge phone call program and by the transitional care program for patients identified as high risk for readmissions

Please let us know if there is anything that we might do to assist and thank you for the great care that you provide our patients!

Real-Time Handover Communications

Interagency standardized transfer form

Warm handover Communication

Work with Clinic and the TCM code

ARNP’s assigned to Post Acute Facilities to oversee care management

Transition Feedback opportunities

Support Programs

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Support Programs

Consistent Care Program (EDCCP) Patients who had Emergency Room visits >12 times in previous 12 months.

Care Plan is developed by a team coordinated by an assigned Social Worker.

Communication tool provides data specific to patient’s medical Hx. and current medical needs, and Goals of Care for when patients presents again.

Advance Medical Team

High Risk patients assigned a Care Navigator to work with them across the continuum.

Team includes resource for Outpatient Social Work and Pharmacy consult for medication management.

Support Programs39

Heart Failure Clinics

MD/NP home visits programs

Outpatient Palliative Care program

Health Care Navigators

ACO case managers

Discharge phone calls program

UCSF Automated Calls Program

Goal: All patients receive a discharge phone call- 80%

Currently: ED, Neuro, Medicine, Ortho, Cardiac

Disease Management

Heart Failure, COPD, AMI

– Specific calls –promotes accountability

– 4-6 additional calls over 30 days

Post Discharge Automated Call Program

HealtheHeart Study

Nurse Avatar “Molly”

Heart Failure management

Calls recorded by Heart Failure Coordinators

Weights, B/P, Heart Rate

Promotes self care management

Inpatient Survey- patients 65+ positive feedback

UCSF Palliative Care Program43

Palliative Care

Palliative care proven to improve symptoms, quality of life,

satisfaction, and patient and family outcomes

25% of our Heart Failure patients die within one year

Up to one- half of deaths with Heart Failure are due to Sudden Death

Palliative care prompts patients to think about all their options in the

future and to start the important discussions for making plans

Standard- consult on 3rd Readmission /Year

New this year, PC MD on Heart Failure Service

Increased palliative care options in outpatient setting- expansion

Pantilat and Steimle JAMA 2004;291:2476-82Wright et al. JAMA 2008;300:1665-73Morrison J Palliat Med 2005;8:S79-87

The Goals of Care Conversation:

When you think about the future what do you hope for?

When you think about what lies ahead, what worries you most?

How do you approach these decisions in “your” family?

Sit and listen

Wait full 2 minutes without a wordSteve Pantilat, MD

Director of the UCSF Palliative Care Program

Results

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Medicare FFS 30 day Readmissions48

FY 2012 FY 2013 FY 2014FY 2015

YTDAMI 12.3% 15.8% 13.6% 20%CHF 22.3% 17.0% 18.4% 16.6%

COPD 17.5% 13.5% 16.2% 23.9%PNA 18.1% 13.3% 14.6% 6.9%

Index 67 readmit 16

Index 40 readmit 8

HF – 75%

of patients in

Transitions

Program

UCSF Readmission Dashboard

Results

HCAHPS RESULTSDISCHARGE INFORMATION (% Yes)

The following questions make up this composite measure:

#19 – During hospital stay, did doctors, nurses or other hospital staff talk about whether you would have the help

you needed when you left the hospital?

#20 - During hospital stay, did you get the information in writing about what symptoms

or health problems to look out for after you left the hospital?

Lessons Learned

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Lessons Learned

Importance of engaged executive leaders and physicians.

Patients and families help transform care in profound ways.

The patient and family home environment must be understood.

Involving frontline staff in the changes helps them understand why they are important and grows ownership by engaging them in redesign.

Lessons Learned (cont)

The role of Information Technology in the process should be addressed simultaneously with the work.

Ongoing monitoring of Process and Outcome Measures is important to hardwiring best practices.

Using patient stories unleashes energy and participation that becomes evident in process and outcome results.

The power of relationship building and collaboration of the cross-continuum team builds new ideas to work and removes many of the “silos’ in the care.

Lessons Learned…

Collaboration with IHI – extremely valuable

Dedicated Heart Failure/Disease Management

Program Coordinators - accountable, reliable

processes

Willingness to test, trial, and change interventions

Make efforts to move outside of silos

Senior Leadership and Champions necessary

Cohesive, committed multidisciplinary cross

continuum teams

Lessons Learned…

Palliative Care Team Collaboration

Home Care collaboration and referrals

Outpatient program & Community Partners essential

Results are not immediate – takes time to show

improvement

Teach Back works – focus on Health Literacy

Technology – great potential – Here to stay

Power of the patient story to learn from and drive change